Premature mortality and socioeconomic inequalities in Mexico
Authors: Mariana Álvarez-Aceves, Juan Eugenio Hernández-Ávila
Journal: The Lancet Public Health (2023)

Socioeconomic status has been identified as a crucial factor affecting mortality rates, particularly in low-income and middle-income countries (LMICs).1Williams J Allen L Wickramasinghe K Mikkelsen B Roberts N Townsend N A systematic review of associations between non-communicable diseases and socioeconomic status within low- and lower-middle-income countries.J Glob Health. 2018; 8020409Crossref Scopus (99) Google Scholar It is important to better understand the determinants of premature mortality and implement targeted interventions to address the disparities in health, health-care access, and quality of care. The Article by Thomas Addey and colleagues2Addey T Alegre-Díaz J Bragg F et al.Educational and social inequalities and cause-specific mortality in Mexico City: a prospective study.Lancet Public Health. 2023; 8: e670-e679Summary Full Text Full Text PDF Scopus (1) Google Scholar in The Lancet Public Health shows that large educational inequalities prevail in adults, and that they are associated with premature mortality in Mexico. This is an important contribution to the literature. Indeed, socioeconomic determinants of the burden of diseases have been insufficiently studied in Mexico. There is a need to deepen understanding of these issues. Prospective cohort studies produce strong evidence in epidemiological research. However, they can have the disadvantage of being highly resource-intensive and time-consuming. As an alternative, probabilistic linkage offers the possibility of following-up individuals through administrative records and mortality data.3Quezada-Sánchez AD Espín-Arellano I Morales-Carmona E et al.Implementation and validation of a probabilistic linkage method for population databases without identification variables.Heliyon. 2022; 8e12311Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar In this context, the Article by Addey and colleagues2Addey T Alegre-Díaz J Bragg F et al.Educational and social inequalities and cause-specific mortality in Mexico City: a prospective study.Lancet Public Health. 2023; 8: e670-e679Summary Full Text Full Text PDF Scopus (1) Google Scholar makes a valuable contribution by providing evidence of the feasibility of using probabilistic linkage with the epidemiological and statistical system of death records of Mexico. Moreover, the long-term impact of health insurance on health status and mortality, as well as the association between education level and access to social security are important issues. In Mexico, access to health care is subject to employment status,4Hernández-Ávila JE Palacio-Mejía LS Hernández-Romieu A Bautista-Arredondo S Sepúlveda Amor J Hernández-Ávila M Implementation and operational research: effect of universal access to antiretroviral therapy on HIV/AIDS mortality in Mexico 1990–2011.J Acquir Immune Defic Syndr. 2015; 69: e100-e108Crossref PubMed Scopus (19) Google Scholar, 5Organisation for Economic Co-operation and DevelopmentOECD reviews of health systems: Mexico. OECD Publications, Paris2005Google Scholar and higher schooling grade and income have been associated with lower risk of employment turnover and losing job-related rights to health care.6Guerra G Gutiérrez-Calderón E Salgado de Snyder N Borja-Aburto VH Martínez-Valle A González-Block MÁ Loss of job-related right to healthcare associated with employment turnover: challenges for the Mexican health system.BMC Health Serv Res. 2018; 18: 457Crossref PubMed Scopus (7) Google Scholar How socioeconomic factors and education are associated with health is not always clear in the published literature. For instance, an analysis of adult obesity trends in 2018–19 revealed no significant differences based on socioeconomic status.7Barquera S Hernández-Barrera L Trejo-Valdivia B Shamah T Campos-Nonato I Rivera-Dommarco J Obesidad en México, prevalencia y tendencias en adultos. Ensanut 2018–19.Salud Publica Mex. 2020; 62: 682-692Crossref PubMed Scopus (65) Google Scholar In contrast, a study in a highly marginalised region of Mexico found a higher likelihood of being overweight and obesity among individuals with higher educational levels, non-indigenous backgrounds, and lower levels of marginalisation.8Vázquez-Durán M Jiménez-Corona ME Moreno-Altamirano L et al.Social determinants for overweight and obesity in a highly marginalized population from Comitán, Chiapas, Mexico.Salud Publica Mex. 2020; 62: 477-486Crossref PubMed Scopus (2) Google Scholar Diet quality has been scarcely analysed in longitudinal studies in association with education level; however, low education level has been found to be associated with poor diet, regardless of income.9Romero I Díez J Del Cura I Franco M Gullón P Diet quality changes by educational level among adults in Spain from 2017 to 2021.Nutrients. 2023; 15: 858Crossref PubMed Scopus (2) Google Scholar Income is closely related to the level of education. Women in Mexico face greater difficulties in accessing education and formal employment than men, as Addey and colleagues2Addey T Alegre-Díaz J Bragg F et al.Educational and social inequalities and cause-specific mortality in Mexico City: a prospective study.Lancet Public Health. 2023; 8: e670-e679Summary Full Text Full Text PDF Scopus (1) Google Scholar noted. Unfortunately, women were excluded from the analysis of the relationship between income and mortality, due to the way income data were collected. In Mexico, as in many other LMICs, a large proportion of women are responsible for family care and household chores and do not receive a personal income. Efforts should be made to put a value on those labours. The premature death of these women represents a great burden in terms of lost productivity and has to be accounted for. Diabetes, ischaemic heart disease, and chronic kidney disease are among the main causes of disability and years of life lost in Mexico.10Parra-Rodríguez L González-Meljem JM Gómez-Dantés H et al.The burden of disease in Mexican older adults: premature mortality challenging a limited-resource health system.J Aging Health. 2020; 32: 543-553Crossref PubMed Scopus (16) Google Scholar The strong associations between education and diabetes complications found by Addey and colleagues suggest the crucial role of addressing inequities in access to education in lowering premature mortality in Mexico. The prevention and control of these diseases and their complications should be prioritised by public health authorities. Strategies to support healthy living should be planned considering actions to bridge the large gaps in access to education and health care, especially for women. Although limited to two districts in Mexico City, the work by Addey and colleagues strongly suggests that gender inequalities in access to formal education, health care, and work opportunities prevail. Another key message is that the strong relationship between level of education and premature mortality is mediated by modifiable lifestyle factors, in turn related to education level. Further research and cross-sectoral collaborations are needed to identify and implement effective strategies to reduce premature mortality in Mexico and other LMICs, with a particular emphasis on bridging socioeconomic inequalities. Such efforts are essential to achieve substantial improvements in public health outcomes and work towards the UNs' Sustainable Development Goal of reducing premature mortality by a third by 2030. We declare no competing interests. Educational and social inequalities and cause-specific mortality in Mexico City: a prospective studyIn this Mexican population there were marked educational inequalities in premature adult mortality, which appeared to largely be accounted for by lifestyle and related risk factors. Effective interventions to reduce these risk factors could reduce inequalities and have a major impact on premature mortality. Full-Text PDF Open Access